Passenger lymphocyte syndrome in liver transplant recipients: a description of 12 cases

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Record number: 
Adverse Occurrence type: 
MPHO Type: 
Estimated frequency: 
During the study period, 1,217 liver transplants were performed, of which 156 (12.8%) with minor ABO incompatibility and 147 (12.1%) with minor Rh incompatibility. Of the 156 cases with minor ABO incompatibility, ten had passenger lymphocyte syndrome (PLS) (17.9%), and two of the 147 patients with minor Rh incompatibility developed PLS (1.4%). Therefore, a total of 12 cases of PLS were detected.
Time to detection: 
The median post-operative time of detection of the first positive DAT was 12.5 days (range, 10-56 days)
Alerting signals, symptoms, evidence of occurrence: 
Passenger lymphocyte syndrome is a relevant clinical syndrome which must be kept in mind as an immune complication of solid organ transplantation. The median age of the patients was 46.5 years; 75% were males and 25% were females. Most of the patients had had a first liver transplant, although one patient had undergone a second transplant procedure. All patients suffering PLS developed haemolysis. The median nadir haemoglobin level was 6.8 g/dl (range, 3.4-8.1 g/dl) on post-operative day 15 (range, day 10 to day 56) and the median peak bilirubin concentration was 5.15 mg/dL (range, 2077-49.15 mg/dL) on post-operative day 134 (range, day 10 to day 59). Of the 12 cases of PLS described, the antibody detected was anti-A in six cases, anti-B in four cases and anti-D in two cases.
Demonstration of imputability or root cause: 
All the donors had a prior, negative indirect antiglobulin test (IAT). All patients suffered from haemolysis with a decrease of haemoglobin (median 6.8 g/dL) and an increase of bilirrubin (median 5.15 mg/dL). In half of the cases, the DAT was positive once, while it was positive more than once in the rest of cases.
Imputability grade: 
3 Definite/Certain/Proven
Groups audience: 
Suggest references: 
Romero S, Solves P, Lancharro A, Cano I, Moscardó F, Carpio N, Sanz MA. (2015). Passenger lymphocyte syndrome in liver transplant recipients: a description of 12 cases. Blood Transfusion 13:423-428.
Expert comments for publication: 
The article should join the already existing articles because it provides 12 new cases of PLS in liver transplant patients, and also a review of the prior literature that includes 56 cases in which antibodies against A and B antigens were detected, nine cases with anti-D, and seven cases in which other red blood cell antibodies were detected. Moreover, the authors suggest the implementation of DAT as a routine pre-transfusion test in order to make an early diagnosis.